1. “I think it is right”: Acceptability of an HIV self-test by lay users in KwaZulu-Natal, South Africa Lucia Knight, Jeanette Lim, Roger Peck & Heidi van Rooyen

2. Background Facility-based HIV Counselling and Testing (HCT) will not result in universal access to testing in sub-Saharan Africa Significantly more people - particularly hard to reach – need to learn their HIV status 1 Rapid scale-up of community-based models of HCT such as self-testing (ST) could improve access by: ▫Bypassing barriers to facility HCT such as lack of privacy, potential stigma 2 ▫Expanding geographic coverage ▫Addressing some of the convenience factors 3

3. Background Evidence about the feasibility and acceptability of HIVST is growing. In Singapore over-the-counter test kits were preferable to other tests because of privacy 4 Kenyan research with health workers and their partners found high feasibility and acceptability of ST 5 To date limited assessment of readiness for and the acceptability of self-tests by lay users Feasibility results from the multi-country study suggest need for fewer steps, better instructions, simpler sample collection and results interpretation 6 This presentation focusses on the acceptability of ST among lay users in South Africa

4. Methods Purposively selected lay users from rural and peri- urban KwaZulu-Natal, South Africa ▫represent geographic, social and demographic profile of community The study tested 5 functional prototype HIV self-tests with 10 lay users for each Simple post-test quantitative assessment addressed ▫ease of and confidence with use ▫future use of a test if available and/or free ▫willingness to buy Qualitative interviews explored in-depth ▫what people liked about the self-test and why ▫willingness to recommend ▫how much they would pay for a test

5. Results: Likability 80% of the respondents felt the test was easy to use. Qualitative assessments of likability were overwhelmingly positive regardless of test prototype. I did not find it that difficult… I’m always confident. Rural, male, 27 years. [The ST] was easy and good…initially I was a bit nervous because I was just starting. But now I’m getting more free, I’ve seen how it works. Urban, male, 61 years. I feel that testing yourself is right. Urban, female, 32 years.

6. Results: Likability Likability was often linked to the privacy and autonomy of the ST I liked that it was private. There is no one with me…I liked the privacy aspect. When there is someone else I don’t feel free. Rural, female, 21 years. …you do [the ST] in solitude, I think that its up to me how I accept if I found a positive result, before someone else sees me I should first counsel myself... Rural, female, 35 years. I was alright when testing myself. I was also confident, I was not scared….Everyone has to know their health condition. Rural, male, 27 years.

7. Results: Likability ST helped remove the barriers presented by the clinic and ensured confidentiality. …because I was alone, I was comfortable to use it and I had enough time, I was not worried about a queue of people behind me waiting to be tested, and not being discriminated against by the person next to you. So it was good. Rural, male, 33 years. I felt good using it because you can use it on your own, without people watching you, curious to see your results…it easy for one to keep their result a secret. Rural, male, 24 years.

8. Results: Willingness to buy Almost all would conduct the test again if it was free (98%). Most being willing to buy a test (86%). The actual amount varied but indicated willingness. I:How much would you expect to pay if this was being sold? P:In terms of the price I would not be able to say much but we get help maybe if we can get it for R30. Rural, male, 38 years. I think I could pay close to R150…we normally want to get these things for free, but things that involve your life, you have to be prepared to part with your money. Rural, male, 33 years.

9. Results: Recommendations Most people would recommend self-test use to others. It was not difficult... So everybody can do it. Urban, male, 60 years. …everybody should get tested, young and old, because this virus does not discriminate. Young or old, well behaved or not, this is for everybody. Rural, male, 33 years. I would recommend [ST] because most of the time people do not like to go to the clinic. [They] do not want to go [to the clinic] because it is far away and most people complain about the time they spend there without getting help and end up changing their minds and go back home and end up not doing what they came for. Urban, female, 32 years.

10. Results: Concern about performance Although many were happy with the test Eh according to my opinion everything is right about it…everything is clear but when you have to start doing you become nervous, you might end up doing it wrong. Urban, female, 32 years. Better test instructions could have reduced difficulties with aspects of the ST. The only thing that I found to be difficult was the thing about the needle, I was not sure how it works. Urban, male, 22 years. I was just not sure to about pricking [my finger]. I did not realize that…I had to [press] this. Urban, female, 18 years.

11. Discussion Despite observed and reported problems with certain aspects of the test process respondents report high usability The acceptability of the test is highlighted by respondents who felt that it facilitated: ▫Confidentiality ▫Privacy ▫Autonomy ▫Removed barriers posed by the clinic Acceptability is also indicated through desire to buy, repeat and recommend ST.

12. Conclusions The broader study raises concerns about test usability and a need for further research to address this 6 The results from this study begin to point to high acceptability and interest in HIV self-testing amongst lay users in a community in KwaZulu- Natal. The positive response and readiness suggests that there may be a ready and willing market for HIV self-tests in similar rural and peri-urban communities.

13. References 1.(Van Rooyen, Richter, Coates, & Boettiger, 2010) 2.(Genberg et al., 2009; Kalichman & Simbayi, 2003; Spielberg, Levine, & Weaver, 2004) 3.(Choko et al., 2011; Frith, 2007; van Dyk, 2013; Wright & Katz, 2006) 4.(Ng et al., 2012) 5.(Kalibala et al., 2011) 6.(Peck et al., 2014)

14. Acknowledgements Participants from Vulindlela Research staff who conducted the interviews